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The California Department of Industrial Relations, Division of Workers’ Compensation may be delaying injured workers’ access to benefits and increasing costs to employers, according to a state audit report released Tuesday that found that the division does not have enough qualified medical examiners to handle caseloads.
The Auditor of the State of California’s report, ordered in February by lawmakers claiming state comp regulators are falling behind in managing the comp system, states that “DWC has not adequately ensured that it has enough QMEs to meet demand and that QMEs are producing high‑quality reports containing the findings of the examinations.”
Qualified medical evaluators are physicians who examine injured workers when disputes arise between the workers and their employers regarding medical issues and benefits in workers compensation claims. They are appointed by regulators, who oversee the process for medical reviews.
The audit found that from fiscal years 2013-14 through 2017-18, the total number of QMEs decreased by 12% while requests for QMEs increased by 37%.
“Without an adequate number of available QMEs, injured workers can experience delays in receiving evaluations and therefore delays in receiving the benefits they need,” the report states.
The audit suggests the state should change the panel selection process for medical evaluators. It also accuses regulators of due-process violations by “inappropriately” using “its reappointment process to discipline some QMEs alleged to have committed overbilling violations, a practice that we believe raises due process concerns,” the audit states.
The report also found that the division has not maintained a standard of review of medical evaluations, stating it “has not continuously reviewed medical‑legal reports, prepared by QMEs and containing the findings of the examinations, for quality and has not tracked when workers’ compensation judges have rejected medical‑legal reports because those reports failed to meet minimum standards.”
The division did not immediately respond to requests for comment.
It did, however, respond to the audit: “The DWC will create and implement a plan in accordance with the Audit recommendations in the hopes of attracting doctors to the QME program. The plan will utilize available data and will also include outreach goals to specific specialties and geographic areas. However, the DWC has seen a decrease in not only QME physicians, but also in treating physicians within our system,” a response published on the auditor’s website states.
The division also stated in its response that “the reasons for a decline in the number of QMEs may be linked to causes outside of DWC’s control. For instance, this decline may be linked to the introduction of medical management companies into the workers’ compensation industry.”
California’s largest workers compensation insurer saw a leap in net income and an increase in premium in 2018 over 2017 numbers, according to the latest annual report released Thursday by the State Compensation Insurance Fund.